Us Family Health Plan Pharmacy Program Medical Necessity Form For Topical Antifungals
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4Medical Necessity Criteria for Topical Antifungals
Drug Class - Topical Antifungals
Background - After evaluating the relative clinical and cost effectiveness of the topical antifungals, the DoD P&T Committee
recommended that the following medications be designated as non-formulary. This recommendation has been approved by
the Director, TMA.
Effective Date: 17 Aug 2005
Ciclopirox (Loprox)
Econazole (Spectazole)
Oxiconazole (Oxistat)
Sertaconazole (Ertaczo)
Sulconazole (Exelderm)
Effective Date: 21 Feb 2007
Miconazole 0.25% / zinc oxide 15% (Vusion)
Patients currently using a non-formulary topical antifungal may wish to consult their doctor to consider a
formulary alternative.
Special Notes:
1. Active duty cost share always $0 in all points of service for all three tiers; Active duty cost share always
$0 in all points of service for all three tiers; TRICARE does not cover non-formulary medications for
active duty service members unless they are determined to be medically necessary.
2. MTFs will be able to fill non-formulary requests for non-formulary medications only if both of the
following conditions are met: 1) a MTF provider writes the prescription, and 2) medical necessity is
established for the non-formulary medication. MTFs may (but are not required to) fill a prescription for a
non-formulary medication written by a non-MTF provider to whom the patient was referred, as long as
medical necessity has been established.
3. Miconazole 0.25% / zinc oxide 15% (Vusion) is FDA-indicated for the adjunctive treatment of diaper
dermatitis (diaper rash) only when complicated by documented candidiasis (microscopic evidence of
pseudohyphae and/or budding yeast) in immunocompetent children 4 weeks of age and older. Other
topical antifungals commonly used for diaper rash include higher concentrations of miconazole (2%),
clotrimazole, and nystatin, often used in conjunction with zinc oxide ointment, an over-the-counter skin
protectant.
Other Considerations:
Some topical antifungals listed above are also available as over-the-counter products, which are not covered by
TRICARE. Visit the Formulary Search Tool page to find if a specific product is over-the-counter.
Brand-name topical antifungal products that have generic equivalents are not covered by TRICARE. Visit the
Formulary Search Tool page to find if a specific product is over-the-counter.
The non-formulary cost share applies to all products designated as non-formulary. Approval of medical necessity for
such products reduces the cost share to the formulary.
The following medical necessity criteria do not apply to Penlac Nail Lacquer (ciclopirox topical solution), which is
available at the formulary cost share; however, prior authorization is required for Penlac.
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